Coronial

77 results for secondary hypoxic injury

VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

Joseph Thurgood-Gates died at 5 days old from global cerebral hypoxic injury due to uterine rupture during labour. The death was preventable. His mother, Ms Thurgood, had two …

obstetricsmidwiferydiagnosticcommunication
VIChospital2012-10-01

Finding into death of Trevor Ronald McDonald

43y · Male·Hypoxic brain injury secondary to haemopericardium and tamponade complicating ru…

Mr Trevor McDonald, 43-year-old male, died from hypoxic brain injury following cardiac tamponade complicating coronary angioplasty. During elective PCI at Franks…

cardiologycardiothoracic surgeryproceduralsystemdiazepam
VIChospital2015-12-10

Finding into death of Dane Alexander Hortle

2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…

…peutic concentrations. The child deteriorated overnight with respiratory depression, seizures, and severe hypoxic-ischaemic brain injury, leading to death despite intensive care. Key clinical failures included: the pres…

ENT surgerypaediatric surgerymedicationcommunicationtramadol
QLDhome2019-04-17

Davis, John

50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolu…

emergency medicineparamedicinediagnosticcommunicationmidazolam
VICmental health2015-08-06

Finding into death of WJ

39y · Female·Hypoxic brain injury secondary to hanging

…athroom and was found unresponsive at 6am. Despite prompt resuscitation and ICU care, she suffered severe hypoxic brain injury and died 7 days later. While the coroner identified process failures requiring remediation, …

psychiatryintensive carediagnosticcommunicationduloxetine
VIChospital2012-10-25

Finding into death of Fikri Memedovski

30y · Male·Heroin overdose

… Order. Dr L. wrote a complex death certificate listing cerebellar tonsillar herniation, cerebral oedema, hypoxic brain injury, and respiratory arrest due to heroin overdose, but did not report to the coroner. The findi…

intensive carepsychiatrycommunicationsystemheroin
VIChospital2009-12-22

Finding into death of Jodi Joy McPaul

33y · Female·Hypoxic brain injury secondary to plastic bag asphyxia

Jodi McPaul, a 33-year-old woman with long-standing schizophrenia and chronic suicide risk, was admitted involuntarily to Frankston Hospital on 29 March 2007. Despite psychiatric team awareness of her vulnerability and p…

psychiatryintensive careolanzapine
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibia…

orthopaedic surgeryanaesthesiasystemenoxaparin
VICmental health2018-02-01

Finding into death of Joy Maree Guppy

59y · Female·Hypoxic ischaemic brain injury secondary to compression of the neck in the circu…

A 59-year-old woman with major depression died by hanging using her dressing gown tie while a voluntary inpatient at a private psychiatric clinic. She was assessed as low-risk and had no restriction on ligature access. D…

psychiatryemergency medicinesystemdiagnosticquetiapine
QLDhospital2016-11-07

Bower, Malaki Ron - Non-inquest findings

2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…

…The following day he suffered cardiorespiratory arrest from upper airway obstruction, resulting in severe hypoxic-ischaemic brain injury and death. Key issues: inadequate observation period; poor documentation of senior…

emergency medicinepaediatricsdiagnosticcommunicationnebulised adrenaline
VIChospital2014-05-29

Finding into death of Lilian Olive Blanche McClurkin

61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…

A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for …

bariatric surgerygeneral surgerycommunicationsystemtramadol
VICinpatient2016-03-03

Finding into death of TK

18y · Female·Hypoxic brain injury secondary to hanging

…oint and a thin fabric (possibly a bed sheet) as a ligature. Despite resuscitation efforts, she died from hypoxic brain injury. The coroner found that clinical management was reasonable, but identified systemic failures…

psychiatryintensive caresystemcommunicationfluoxetine
NSWhospital2021-09-28

Inquest into the death of Gwenith ELKINGTON

60y · Female·acute cerebral bleed resulting from blunt trauma and late haemorrhagic progressi…

…gton, aged 60, died from acute cerebral bleed resulting from haemorrhagic progression of a traumatic brain injury sustained in a bathroom fall on 21 September 2015. The injury caused a contre coup contusion to the opposi…

emergency medicineneurosurgerydelaycommunicationibuprofen
NTcommunity2006-06-29

Inquest into the death of Clifford Brown

58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …

…s that were potentially survivable with appropriate treatment—Nurse Paulus failed to conduct primary and secondary surveys, did not take vital signs, and agreed to transport the deceased to his remote camp rather than t…

emergency medicineparamedicinediagnosticcommunication
VICaged care2011

Finding into death of Mr CR

43y · Male·hypoxic brain injury secondary to asphyxiation by ligature

A 43-year-old man died from hypoxic brain injury due to asphyxiation by ligature while an inpatient at a rehabilitation centre. He had underg…

neurosurgeryrehabilitation medicinecommunicationsystem
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

…ilure to perform timely finger thoracostomy significantly contributed to Adam's 46-minute cardiac arrest, hypoxic brain injury, and death. The rigid adherence to an inadequate airway plan, absence of effective team comm…

intensive careanaesthesiadiagnosticproceduralrocuronium
VIChome2025-03-12

Finding into death of H D

11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…

HD was an 11-year-old girl with severe cerebral palsy, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August …

paediatricspalliative care
VIChospital2009-12-08

Finding into death of Timothy Jack Wood

1y · Male·Cerebral anoxia caused by cardiac arrest caused by bronchiolitis and bronchopneu…

…old boy, died from cerebral anoxia following cardiac arrest caused by bronchiolitis and bronchopneumonia secondary to influenza A infection. He initially presented with croup symptoms on 15 July 2005, was discharged aft…

emergency medicineintensive carecommunicationsystemprednisolone
SAhospital2014-07-08

Coroner's Finding: SLEEP Aurora Doreen Maureen

4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…

Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mo…

obstetricsmidwiferycommunicationdiagnosticprostaglandin gel
NSWPodcast2021-10-29

Inquest into the death of Jesse DRABSCH

31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…

Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…

endocrinologytoxicologysystemproceduralinsulin

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